MODELS OF CLINICAL TEACHING

Types of models of clinical teaching

Three main models used in clinical teaching.
a) Traditional model
b) Preceptor model
c) Clinical teaching associates model
Traditional model
The clinical instruction and evaluation of a group of students
are carried out by an academic faculty member who is on site
during clinical experience.
Benefit of this model;
Provides opportunity to assist students in using the concept
and theories learned in class in their patient care.
Since the clinical teacher is involved with the nursing
curriculum overall, the clinical activities may be more
carefully selected to reflect the concepts and theories that
students are learning in the course.
The faculty member is a member of an educational system
and may be more committed to implementing the philosophy
of the nursing programme than preceptors or faculty hired only
for clinical teaching often on a short-term basis.
Preceptor model
An expert nurse works with the student on a one to one basis in
clinical setting.
Preceptors are staff nurses and other nurses employed by the
clinical agency, who, in addition to their ongoing patient care
responsibilities, provide onsite clinical instruction for the assigned
students.
The preceptor guides and supports the learner and serves as a role
model.
This close relationship promotes socialization, bridges the gap
between theory and practice and allows students to gain an
understanding of how to function in the role for which they are
preparing.
Students are able to work closely with a nurse who is an expert
clinician, develop self confidence, improve the decision making
skills and learn new clinical skills.
Clinical Teaching Associate (CTA) model
A staff nurse instructs a small group of nursing
students in the clinical setting, collaboratively with the
lead teacher from the nursing programme.
The CTA assumes clinical teaching responsibilities
for the students. The faculty member, as the lead
teacher, works with the CTA to coordinate the overall
clinical practicum, design the clinical experiences,
assist in the evaluation of student clinical performance
and serve as a resource in undergraduate clinical
teaching and mentor for the CTA.
Similar to the preceptor model, faculty may not be on
site during the actual clinical activities.
 Methods of clinical teaching
i ) Simulation
Simulations provide experience for students without
the constraints of a real life situation.
With a simulation, students can think through clinical
scenarios and provide care to a hypothetical patient
prior to experience in the actual situation.
Simulations may be in paper and pencil format; use
multimedia; videotapes and interactive video
computer simulations and use of models.
ii) Role play
This is designed for formative evaluation only. Role
play enables a learner to portray a role and assess his
or her performance in that role. Role play is most
appropriate for clinical objectives on developing
communication skills, interpersonal relationships and
working with other health providers.
iii) Media clip
Media clips should be short and students should be
aware of the object lines in advance so they can focus
their observation.
Media clips showing clinical scenarios are particularly
valuable for evaluating critical thinking and problem
solving skills.
Students may be asked to analyse the scenario using
relevant concepts and theories, identify all possible
problems, propose additional data they would collect,
suggest multiple interventions and consider the
various decisions possible and consequences of each.
iv) Problem solving strategies
These are short descriptions of clinical situations for
students to identify problems and solutions.
They involve decision making scenarios requiring one
or more decisions as part of the analysis and critical
incidents where students analyze critical events and
identify actions to take.
v) Case study
This is a hypothetical or a real life situation that
students analyze and prepare responses usually in
written form.

vi) Written assignments

Written assignments accompanying the clinical learning
activities are effective strategies for evaluating students
learning in clinical practice. Depending on the type of
assignment, they may be geared to evaluating students’
ability to apply concepts and theories to clinical
situations, their problem solving, decision making and
critical thinking skills and their writing skills.
vii) Journal
Journals provide an opportunity for students to
describe their clinical experiences and document their
responses to clinical learning activities.
Journals enable students to think aloud and record
their perceptions.
Journals are best used to provide feedback to students,
not for grading clinical performance.
viii) Portfolio
A portfolio is a collection of projects that students
complete in clinical practice that document their
learning and development of knowledge and skills.
Since the products in the portfolio provide
documentation of student learning in clinical practice,
portfolios are valuable for clinical evaluation.
ix) Clinical conference
a clinical conference may be on a one to one basis or
small group format. Outcomes of clinical conferences
may be intellectual; affective; social expressive or
experiential.
 Teaching strategies used in clinical teaching
Types of clinical teaching strategies
1. Clinical laboratory teaching
A learning laboratory may have a single limited
purpose such as skill practice before entering the
clinical environment or it may serve multiple
functions such as a learning resource centre.
Functions of a clinical laboratory
a) Skill development and practice
It is in the clinical laboratory that many skills are perfected.
Skills practice lab also provides opportunities for formative
evaluation of skill performance with plentiful feedback
to the learner.
Because a skills lab allows students to learn and practice
new skills in an environment where mistakes produce no
harmful effects student anxiety related to skill
performance is often reduced.
Problem solving and decision making skills are also refined
in the skills lab.
Learners also gain organizational and time management
skills in the lab.
b) Multipurpose learning resource centre (LRC)
LRC may provide resources such as instructional
media, patient teaching materials reference books and
journals, photocopy equipment, computer hardware
and software for CT and simulations and model for
student and teacher use.
An LRC provides facilities for teaching and learning
in the cognitive, psychomotor and affective domains.
c) Skill demonstration
Skill demonstration is more effective in the learning laboratory
than in the clinical area because the environment can be
controlled, more learners can be accommodated and the skill
demonstration can be repeated as many times as needed.
When demonstrating psychomotor skills to students, you should
keep in mind that skilled performance has cognitive, motor, and
affective components.
Demonstrate the skill and also allow learners to repeat the
demonstration.
You can be physically present for the demonstration or the learners
can view a recorded demonstration on videotape or videodisc.
Use checklist to evaluate repeat skill demonstration and determine
if the student is ready to apply the skill in an actual clinical setting.
2. Simulated patients
Simulations
A simulation creates a scenario that mimics a real life
situation. Simulating provide a way for students to
gain experience in problem solving and decision
making without the realities and demands of an actual
clinical situation. It also allows for the practice of
skills. It is cost effective. It provides essential
experience for developing interpersonal and
relationship skills. With a simulation, the teacher can
control the clinical situation more easily than in actual
practice and as result; can adapt the learning activity
to individual student needs.
At the end of the simulation, a debriefing session or
discussion should be held to:
a) Emphasise the major learning outcomes from
simulated experiences;
b)Reinforce learning that has occurred and relate it to
the objectives;
c)Relate the simulation to actual clinical practice;
d)Identify where further learning is needed;
e)Discuss feelings generated through simulation;
f)Examine changes that may be needed in own
behaviours to better meet patients’ needs.
Types of simulations
a) Active case studies
Information about a clinical situation is presented for
analysis.
The case may depict a situation for problem solving,
decision making or critical thinking, or it may require
application of the concepts and theories being learned in
class for its analysis.
Information is gradually added to the case asking for
different types of decisions and further thinking for
resolution of problems.
Active case studies may be presented in paper and pencil
format, computer simulations and using multimedia.
b) Patient simulator models
These refer to mannequins and models of the breast,
for learning clinical skills and practicing procedures.
These models allow students to practice skills in a safe
environment without distraction and to develop self
confidence in performing them.
c) Simulated patients
This refers to the use of actors or other people to
portray the role of the patient. These help students to
practice taking a health history and performing a
physical examination, etc. Students‟ performance may
be videotaped for evaluation of skills at a later time.
3. Role play
Role playing is closely related to simulation.
A learner portrays a certain role as a way of
experiencing that role or for developing
communication skills.
In role play, the learner is directed as to the role to
portray but usually is given freedom in acting it out.
While students are portraying the assigned roles, other
students in the clinical group observe and analyse the
behaviour.
Other strategies used in clinical teaching
Clinical practice enables students to make decisions
on problems, give interventions, and then evaluate
their effectiveness. Case method, case study, and
grand rounds are effective means in developing these
outcomes.
These equip students with the following skills:
 Problem solving skills
 Skills in decision making
 Skills in critical thinking
CRITICAL THINKING enables the nurse to make
reasoned and informed judgments in the practice
setting and decide what to do in a given situation. It is
reflective thinking about patients’ problems without
one solution.
Through critical thinking the learner:
 Considers multiple perspectives to care
 Critiques different approaches possible in clinical
situation
 Arrives at judgments after considering multiple
possibilities
 Raises questions about issues to clarify further
 Resolves issues with a well thought out approach.
Case method
Case method and case study provide a simulated case
for students to review and critique.
Cases may be developed around actual or hypothetical
patients.
It is effective for applying concepts and theories to
clinical practice and for promoting problem solving,
decision making and critical thinking.
Case method is a useful strategy for helping students
learn how to analyse a case, identify problems and
solutions, compare alternative decisions and arrive at
conclusions about different aspects of patients care.
Case study
A case study provides an actual situation or hypothetical
one for students to analyse and arrive at varied decisions.
Case studies are typically longer and more comprehensive
than in the case method providing background data about
the patient, family and other information for a more
complete picture.
Students can analyse case studies in greater depth than
with case method and present a more detailed rationale
for their analysis.
In their critique of the case study, students can describe
the concepts and theories that guided their analysis how
they used them in understanding the case and literature
they reviewed.
Grand rounds
These involve the observation and often interview of a
patient or several patients in the clinical setting,
focusing on a particular condition or treatment.
They may be conducted for nursing personnel only or
as an interdisciplinary activity.
Rounds provide an opportunity to observe a patient
with a specific condition. Review assessment data and
discuss interventions care.
Grand rounds might include the following areas for
discussion;
Review of relevant pathophysiology
Background information about the patient
Patients history including reason for admission
Past medical history
Relevant test results
Family history
Nursing diagnosis and care
Interdisciplinary referrals,
Related research
Patient outcomes.
In some instances, procedures might be demonstrated
with the patient‟s permission.
Grand rounds may be conducted by an advanced
practice nurse, a staff nurse, the teacher student, or
another health professional.
For student led rounds you as the teacher is
responsible for confirming the plan with the patient.
Patients should be assured of their right to refuse
participation and should be comfortable to tell the
student or teacher when they no longer want to
continue with it.
Grand rounds enable students to achieve the following.
 Identify patients problems and issues in clinical
practice.
 Evaluate the effectiveness of nursing and
interventions.
 Share clinical knowledge with peers and identify gaps
in own understanding.
 Develop new perspectives to care.
 Gain insight into other ways of meeting patients’
needs.
 Think critically about the nursing care they provide
and that given by peers.
Dialogue is carried out about patients care and
changes in nursing practice with peers and experts
participating in the rounds.
The teacher’s role is that of consultant, clarifying
information and assisting the student in keeping the
discussions on the goals set for the rounds.
You should ask questions and discuss sensitive issues
after the rounds are completed and out of the patient’s
presence.
Grand nurse rounds
Grand nurse rounds may be conducted by an advanced
practice nurse, staff nurse, clinical instructor, student or
another professional.
Rounds involve the observation and often interview of
a patients or several patients in the clinical setting,
focusing on a particular condition or treatment.
Nurse rounds provide an opportunity to observe a
patient with:
 specific condition
 review assessment data
 Discuss interventions and their effectiveness and
make changes in the plan of care.
Depending on the objectives, nurse rounds might
include the following areas for discussion.
 Review of relevant pathophysiology
 Background information about the patient
 Patient history including reasons for admission
 Past medical history
 Relevant test results
 Family history.
Student led rounds
In student led rounds, students discuss a concept related to the
care of an individual patient.
Students present the topic at patient’s bed side for discussion
with the patient and family and for later analysis by the group.
Patients should have a right to refuse being discussed at the
bedside.
Begin with introduction of patient to the students, emphasizing
the patient’s contribution to students learning.
Your role is that of a consultant, clarifying information and
assisting the student in keeping the discussion on the goals set
for the rounds.
Sensitive issues should be asked and discussed after the rounds
are completed and out of patient’s presence.
Rounds help students to:
 Identify patients’ problem and issues in clinical
practice
 Evaluate effectiveness of nursing and
interdisciplinary interventions
 Share clinical knowledge with peers
 Develop new perspectives to care
 Gain insight into other ways of meeting patients’
needs
 Think critically
 Dialogue about patients care and changes in nursing
practice.
Clinical team conferences
These are discussions held in the clinical setting in
which students share information about a client, lead
others in discussions about clinical practice, present
ideas in a group format, give formal presentations to
the group.
Goal: problem solving, decision making, critical
thinking skills, debriefing clinical experiences,
develop oral communication skills, assessing own
learning and developing cooperative learning.
Types of team conferences
a) Preclinical conferences – these precede clinical
activities.
b) Post clinical conferences – this is held at the
conclusion of clinical learning activities.
It provides a forum for discussing the clinical
activities, analyzing clinical situations, expressing
feelings and developing support systems among the
students.
They may also be used for peer review, critiquing each
other’s work
Others
 Issue conferences
 Interdisciplinary conferences: collaborative planning
and decision making
 Critical incident conferences
 Debates
Roles of teacher in discussion
 Instructor
 Plans discussion
 Presents problem, issue, case for analysis
 Develops questions for discussions
 Facilitates discussion and encourages students to
participate
 Develops and maintains atmosphere for open
discussion of ideas and issues
 Keeps time
 Avoids side tracking
 Provides feedback
Roles of student in discussion
 Prepares for discussion
 Participates actively in discussion
 Works collaboratively with group members to arrive at
solutions and decisions
 Examines different points of view
 Willing to modify own view and perspective to reach
group consensus.
Roles of teacher and student in discussion
 Summarize outcomes of discussions
 Relate discussion to theory and research
 Identify implications of discussion for other clinical
situations
 Writing a clinical report
Procedure:
a) Title page – cover page
b) Introduction
General information such as ownership, mission statement,
goals, objectives, physical location, catchment area of
institution, whether conducting case study, duration of
placement.
c) Description of placement: look at the structural and
organizational services, the human resources, routine activities,
standard setting; and monitoring of nursing care.
d) Activities: what were you effectively involved in;
responsibilities.
e) Case study: look at the condition of the patient; nurse or staff
activity, or area of concern.
 EVALUATING CLINICAL
LEARNING PERFORMANCE
Formative Evaluation
Formative evaluation provides information about
further learning needs of students and where
additional clinical instruction is needed.
It is the clinical evaluation that is not intended for
grading purposes but is instead designed to diagnose
learning needs as a basis for further instruction.
Summative Evaluation
Summative evaluation provides the basis for
determining grades in clinical practice or certifying
competency.
It occurs at the completion of the course, an
educational programme, orientation programme, and
other types of programmes.
Summative evaluation determines what has been
learned rather than what can be learned.
Selecting method of evaluation
The following should be considered:
1. Should determine how well students are meeting clinical
objectives if formative, or extent to which they achieved
these objectives. If the purpose is summative; what are the
clinical objectives to be evaluated?
2. Varying the evaluation strategies provides a broader
database for judging students performance.
3. Should be appropriate for the type of clinical activities in
which students engage in.
4. Be clear about whether the evaluation is for summative
or formative purposes.
5. An evaluation method should take into cognizance
faculty time for completing the evaluation.
Clinical evaluation methods
1. Rating scale
This provides a means of recording the teacher’s
observations and judgments about student’s performance
in clinical practice and a scale for rating the performance.
Scales may be multidimensional such as ABCDE,
outstanding, very good, good, fair, poor or two
dimensional such as pass/fail, satisfactory/ unsatisfactory.
Rating scales are only effective if the teacher or another
expert has an opportunity to observe performance over a
period of time.
They more effective if combined with other evaluation
strategies that do not rely on observation of performance.
2. Checklist.
This includes a list of steps to be followed in
performing a procedure or carrying out a specific
technique or intervention. The checklist should not
include every possible step in a procedure but instead
should focus on critical steps and their sequences.
3. Anecdotal scale
Anecdotal note is a narrative description of the
teacher’s observation of students in clinical practice.
The anecdotal note may describe only the behaviours
observed or may also include the teacher’s
interpretations or judgments about performance.
Observations made of students and recorded in
anecdotal notes should always be discussed with
students, allowing for student input into the
observations made and teachers interpretation of them
Anecdotal notes are valuable for giving feedback to
learners and gathering their own perception of
performance.
Evaluation and feedback in clinical setting
1. Formative evaluation
Through formative evaluation the teacher monitors
students’ progress toward meeting the clinical objectives
and demonstrating competency in clinical practice.
Formative evaluation provides information about further
learning needs of students and where additional clinical
instruction is needed.
Clinical evaluation that is formative is not intended for
grading purposes. Instead it is designed to diagnose
learning needs as a basis of further instruction.
Formative evaluation can be achieved through effective
feedback.
Effective feedback
a) Descriptive and non-evaluative
Instructors should describe the performance of the student in
terms of the following.
 Consequences of that student performance, for example, the
differential diagnosis did not include the possibility of
infection.
 Specific suggestions should provide feedback for
improvement to the student
 Behaviorally anchored
 Well timed
 Positive as well as corrective feedback
 Anticipatory guidance
 Develop a personal feedback mechanism.
b) Problem solving strategy
Problem solving strategy provides opportunity to the
students for analyzing and solving a problem on the
basis of the previous stock of their knowledge
enriched with the present means available to them,
quite independently by following some systematic
steps and arriving at some basic conclusion or results
to be utilized in future for the solution of the similar
problem in identical solution.
Steps to problem solving strategy
Confront the problem
Describe understanding of the problem
Gathering relevant information or data
Analysis of the collected data or information
Formulation of hypothesis or tentative plans for
solution of problem
Selection and testing of a proper hypothesis
Application of the accepted hypothesis or conclusion
c) Demonstration
This refers to the visual presentation of the action and
activities or practical work related to the facts and
principles of a delivered lesson by the teacher in the
classroom, aiming to facilitate the task of teaching and
learning.
 Methods of evaluation in clinical teaching
i) Written assignments
These enable students to develop problem solving and
critical thinking skills, learn about concepts and
theories for clinical practice, examine values and
beliefs that may affect patient care and at the same
time improve writing skills.
Written assignments about clinical practice combined
with feedback from the teacher provide an effective
means of developing students’ writing abilities.
Purpose of written assignments
1) Assist students in understanding concepts and
theories that relate to care of the patients.
2) Improve problem solving and critical thinking
skills.
3) Examine their own feelings, beliefs and values
generated from their own feelings and beliefs and
values generated from their clinical learning
experiences.
4) Develop writing skills.
Types of written assignments for clinical learning
a) Nursing care plan
A nursing care plan enables students to analyze patients’ health
problems and design plans of care.
b) Concept maps
A concept or cognitive map is a graphic or pictorial arrangement of
key concepts that relate to patients care.
Concept may represent a hierarchical structure of concepts that help
students connect new information and retain knowledge more
effectively over time.
Mapping concepts visually help students connect ideas together in a
meaningful way.
A concept map acts as a roadmap for students, showing important
concepts related to patient care and the pathways that connect them.
A concept map is a two dimensional schematic device composed of
concepts and linking words or symbols arranged in hierarchy.
Steps of developing concept maps
1. Diagram pertinent conditions such as COPD – renal
insufficiency and congestive heart failure.
2. Cluster data and clinical manifestations with
appropriate concept such as K+, creatinin , BuN.
3. Cluster data and therapeutics with appropriate
concepts such as digoxin with CHF.
4. Link the concepts by arrows, direct lines or broken
lines indicating the nature of the relationship.
c) Concept analysis paper
Concept analysis paper - concepts related to clinical
practice help students understand difficult concepts
and how they are used in patient care.
For these paper students identify and define concept
such as chronic pain.
Examine characteristics and attributes of the concept
Develop or present clinical cases that reflect the
concept related to nursing interventions and rational.
Do as to their effectiveness and describe how the
concept is operationalized.